Minimal Incision And Less Invasive Techniques In Congenital Cardiac Surgery
Laszlo Kiraly1, Maung WM Aye1, Senthil K. Subbian1, Theodoros Kofidis1, Bassem N. Mora2.
1National University Hospital Singapore, Singapore, Singapore, 2Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates.
BACKGROUND: Minimal incision and less invasive techniques derive from adult cardiothoracic surgery and they gradually find their application in congenital cardiac surgery. The final aim is a cosmetically more appealing result without jeopardizing quality of the repair and patient-safety. Our bi-institutional experience is presented as a team-learning and program developmental process. METHODS:
Methods: Preoperative preparation included advanced imaging to establish full segmental diagnosis and spatial anatomy to identify the exact site of entry. Surgical approach was discussed in close communication with and consented by patients/guardians. Solitary anomalies (ASD, SV-ASD, VSD, subaortic membrane, MV surgery, PVR, etc.) were approached by a muscle-sparing minithoracotomy. Multi-compartment anomalies (e.g., complete repair of tetralogy of Fallot, aortic arch anomalies associated with intracardiac repairs) were addressed by ministerotomy. Intraoperative visualization was helped by superimposed 3D virtual models and endoscopy. Peripheral cannulation for CPB was employed above 30kg of bodyweight. Endoscopic instruments and additional analgesia catheters were utilized in the thoracotomy group.
RESULTS:
Results: Patients ranged from 3 months - 64 years (median ages, thoracotomy: 14.5 years; ministernotomy: 28 months, p=0.001). No major morbidity/mortality occurred. In the thoracotomy group a transient brachial plexus neuropraxia prompted for a change in patient-positioning. Superimposed images improved direct access to region-of-interest, the use of endoscopic imaging and instruments accelerated the learning curve and broadened the scope of eligible anomalies. Limited midline incision with/without full opening of the sternum with the use of special retractors allowed adequate visualization of all areas-of-interest and complete repair. Over 85% of eligible patients are now routinely undergo even complex congenital cardiac surgery with minimal incision and less invasive techniques at our institutions.
CONCLUSIONS:
Diffusion of minimal incision and less invasive techniques into congenital cardiac surgery has so far been restricted due to complexity, need to access multiple segments in a constrained operative field. These techniques require a dedicated team acquiring new skills, working in cooperation with the allied disciplines, using specialized instruments. Advanced pre- and intraoperative visualization could offer uncompromised view and access that translate into improved quality of the repair and patient-safety and more appealing cosmesis.
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